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SCHEDULE A (FEC Form 3X) ITEMIZED RECEIPTS

Use separate schedule(s) for each category of the Detailed Summary Page

FOR LINE NUMBER: (check only one)
11a 13 11b 14

PAGE 10451OF 18187
11c 15 12 16 17

Any information copied from such Reports and Statements may not be sold or used by any person for the purpose of soliciting contributions or for commercial purposes, other than using the name and address of any political committee to solicit contributions from such committee. NAME OF COMMITTEE (In Full)

ROMNEY VICTORY, INC.
Full Name (Last, First, Middle Initial)

A. MR. JOHN E. MELBON
Mailing Address 25 BALBOA COVES City NEWPORT BEACH FEC ID number of contributing federal political committee. Name of Employer
U.S.I. INSURANCE SERVICES Receipt For: Primary General Other (specify)

Date of Receipt
M M / D D / Y Y Y Y

State CA

Zip Code 92663-3226

10 16 2012 Transaction ID : SA11.3540233

Amount of Each Receipt this Period

C
Occupation
CONSULTANT

,฀

,฀

250.00

.

CONTRIBUTION

Aggregate Year-to-Date

,฀

,฀

250.00

.

Full Name (Last, First, Middle Initial)

B. ALAN MELCHIOR
Mailing Address 2221 E. 6200 SO. City
SALT LAKE CITY

Date of Receipt
M M / D D / Y Y Y Y

10

13

2012

State UT

Zip Code
84121-2203

Transaction ID : SA11.3430071 Amount of Each Receipt this Period

FEC ID number of contributing federal political committee. Name of Employer FUTURE 2000 LC Receipt For: Primary Other (specify) General

C
Occupation
OWNER

,฀

,฀

250.00

.

CONTRIBUTION

Aggregate Year-to-Date

,฀

,฀

460.00

.

Full Name (Last, First, Middle Initial)

C. MRS. ANDREA MELCHIORRE
Mailing Address 150 WESTERN DRIVE City SHORT HILLS FEC ID number of contributing federal political committee. Name of Employer
HOMEMAKER Receipt For:

Date of Receipt
M M / D D / Y Y Y Y

10

08

2012

State NJ

Zip Code 07078-1933

Transaction ID : SA11.3252026

Amount of Each Receipt this Period

C
Occupation
HOMEMAKER

,฀

,฀

10000.00

.

CONTRIBUTION

Aggregate Year-to-Date General

Primary Other (specify)

,฀

,฀

30000.00

.

SUBTOTAL of Receipts This Page (optional) ............................................................................ TOTAL This Period (last page this line number only) ...............................................................

฀ ฀

,฀ ,฀

,฀ ,฀

10500.00

. .

FE6AN026

FEC Schedule A (Form 3X) Rev. 02/2003

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